notification of formulary changes the following …docs.phs.org/cs/groups/public/documents/... ·...

Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.

MPC011711 of 14 Updated 09/01/2020

NOTIFICATION OF FORMULARY CHANGES

The following summary describes changes to the Presbyterian Individual and Family Metal Plan/Employer Group Metal Plan Formularies effective 2020.

For the most recent list of drugs, information on obtaining a coverage determination or exception, or other questions, please contact the Presbyterian Customer Service Center. You can reach

them Monday through Friday from 8:00 a.m. to 5:00 p.m.

Phone: (505) 923-5678 or 1-855-356-2219

TTY: 711 Online: www.phs.org

Effective Date

of Change

Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable

for formulary removals)

01/01/2020 Actemra (tocilizumab)

162mg/0.9mL auto-injector and pre-filled

syringes

Formulary Addition T5, PA, SP, QL

01/01/2020 Afirmelle (levonorgestrel/ethinyl estradiol)

0.1mg/20mcg tablet

Formulary Addition $0

01/01/2020 Aubagio® (teriflunomide)

7mg, 14mg tablet

Criteria Removal T5, QL, SP

01/01/2020 Avonex® (interferon beta-1A)

30mcg/0.5ml auto-injector and prefilled

syringe; 33mcg(6.6mu) vial


01/01/2020 Ayuna (levonorgestrel/ethinyl estradiol)

0.1mg/30mcg tablet

Formulary Addition T2

01/01/2020 Baqsimi (glucagon)

3mg intranasal device


http://www.phs.org/


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



01/01/2020 benzphetamine HCl (generic for Didrex®)

25mg, 50mg tablet

Formulary Addition T4, PA, QL

01/01/2020 Berinert® (C1 esterase inhibitor, human)

500unit kit

Criteria Update T5, PA, SP

01/01/2020 budesonide (generic for Entocort EC®)

3mg capsule

Quantity Limit added T4, QL

01/01/2020 Cimzia® (certolizumab)

200 mg single dose vial, 200 mg/mL prefilled

syringe, 200mg/mL x 6 prefilled syringes

starter kit


01/01/2020 Cinryze® (C1 esterase inhibitor, human)

500unit Kit


01/01/2020 Darzalex® (daratumumab)

100mg/5mL and 400mg/20mL single-dose vial

Formulary Addition MB, PA

01/01/2020 Dexcom G6 receiver device Formulary Addition T3, PA, QL

01/01/2020 Dexcom G6 Sensor Formulary Addition T3, PA, QL

01/01/2020 Dexcom G6 Transmitter Formulary Addition T3, PA, QL

01/01/2020 diethylpropion HCl (generic for Tenuate®)

75mg extended release and 25mg immediate

release tablet


01/01/2020 Dotti (estradiol)

0.025mg/24hr,0.0375mg/24hr,0.05mg/24hr,

0.075mg/24hr,0.1mg/24hr

Formulary Addition T2, QL

01/01/2020 Dulera® (mometasone furoate/formoterol

fumarte dihydrate) 50mcg/5mcg/actuation

Formulary Addition T4, ST, QL


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



01/01/2020 Enbrel®(etanercept)

50 mg/mL auto-injecctor, cartridge, prefilled

syringe; 25 mg/0.5mL prefilled syringe

Formulary Removal NF

01/01/2020 Entyvio® (vedolizumab)

300mg vial


01/01/2020 Ery-TAB (erythromycin)250mg,333mg,500mg

Delayed Release Tablet


01/01/2020 famotidine oral suspension

40mg/5ml


01/01/2020 Flucelvax® Quadrivalent (influenza virus

vaccine (subvirion))

60mcg/0.5mL

Formulary Addition $0, QL

01/01/2020 Flumist® (influenza virus vaccine (live))

0.1mL intranasal suspension

Formulary Addition $0, QL, AL

01/01/2020 Freestyle Libre® 14 day reader device Formulary Addition T3, PA, QL

01/01/2020 Freestyle Libre® 14 day sensor Formulary Addition T3, PA, QL

01/01/2020 Freestyle Libre® Reader Device Formulary Addition T3, PA, QL

01/01/2020 Freestyle Libre® Sensor System Formulary Addition T3, PA, QL

01/01/2020 Haegarda® (C1 esterase inhibitor, human)

2000unit, 3000unit

Formulary Addition T5, PA, SP

01/01/2020 Hailey (norethinedrone/ethinyl estradiol)

1.5mg/30mcg Tablet


01/01/2020 icatibant (Generic for Firzayr®)

30mg/3ml Syringe



MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



01/01/2020 isosorbide dinitrate

30mg tablets

Tier Change (moved from T2 to T3) T3

01/01/2020 isotretinoin

20mg, 30mg, 40mg capsule

Formulary Addition T4, PA, QL, AL

01/01/2020 Jakafi® (ruxolitinib)

5 mg, 10 mg, 15 mg, 20 mg, 25 mg tablet

Criteria Update T5, PA, QL, SP

01/01/2020 Kalbitor® (ecallantide)

10mg/ml vial

Formulary Addition MB, PA, SP

01/01/2020 Kalliga (desogestrel/ethinyl estradiol)

0.15mg/30mcg Tablet Formulary Addition $0

01/01/2020 Kalydeco (ivacaftor)

150 mg tablets; 25mg, 50mg, 75 mg packets

Criteria Update T5, PA, SP, QL

01/01/2020 Kombiglyze Xr® (saxagliptin/metformin)

2.5/1000mg, 5/1000mg, 5/500mg

Criteria Update T4, PA, QL

01/01/2020 Latuda® (lurasidone)

20mg, 40mg, 60mg, 80mg, 120mg

Criteria Update T4, PA, QL, AL

01/01/2020 Lo-Zumandimine (drospirenone/ethinyl

estradiol)

3/0.02mg tablet


01/01/2020 Mavyret® (glecarprevir/pibrentasvir)

100/40mg tablet


01/01/2020 methylphenidate (generic for Methylin®)

5mg/5ml, 10mg/5ml solution


01/01/2020 Nubeqa ® (darolutamide)

300mg tablets

Formulary Addition T5, PA, QL, SP

01/01/2020 Onglyza® (saxagliptin HCl)

2.5mg, 5mg

Criteria Update

T4, PA, QL


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



01/01/2020 Orencia® (abatacept)

125mg/mL auto-injector; 50mg/0.4mL, 87.5

mg/0.7 mL, 125 mg/mL prefilled syringes


01/01/2020 Otezla®(apremilast)

10 mg, 20 mg, 30 mg tablet ,30 mg Therapy

pack


01/01/2020 oxazepam

10mg,15mg,30mg capsule

Tier Change (moved from T2 to T3) T3, QL Lorazepam tablet (0.5mg, 1mg, 2mg)- T2, QL

01/01/2020 phendimetrazine (generic for Bontril®)

105mg extended release and 35mg immediate

release tablet


01/01/2020 Piqray® (alpelisib)

50mg, 150mg, 200mg tablets


01/01/2020 Polivy® (polatuzumab vedotin-piiq)

140mg vial


01/01/2020 Rebif® (interferon beta-1A)

22mcg/0.5ml, 44mcg/0.5ml auto-injector,

prefilled syringe, 4.2ml titration kits)


01/01/2020 Remicade® (infliximab)

100mg/20ml vial

Criteria Update MB, PA, SP

01/01/2020 Renflexis® (infliximab-abda)

100mg/20ml vial


01/01/2020 Rinvoq® (upadacitinib)

15mg tablet Formulary Addition T5, PA, SP, QL

01/01/2020 Simpesse® (levonorgestrel/ethinyl estradiol

(ee))

0.15mg/0.03mg (84) & ee (7)



MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



01/01/2020 Skyrizi®(risankizumab)

75mg/0.83mL prefilled syringe


01/01/2020 solifenacin (generic for Vesicare®)

5mg, 10mg

Tier Change (moved from T4 to T2) T2, QL

01/01/2020 Soliris® (eculizumab)

300 mg/30 mL vial


01/01/2020 Spiriva Respimat ® (tiotropium bromide)

1.25mcg/actuation inhaler Formulary Addition T3

01/01/2020 Stelara®(ustekinumab)

45mg/0.5mL subcutaneous solution;

45mg/0.5mL prefilled syringe


01/01/2020 Symdeko®

(tezacaftor 50mg/ivacaftor 75mg; ivacaftor

75mg)


01/01/2020 Symjepi® (epinephrine)

0.15mg/0.3ml injection solution


01/01/2020 Takhzyro® (lanadelumab-flyo)

300mg/2ml vial

Formulary Addition T5, PA, SP

01/01/2020 Taltz®(ixekizumab)

80mg/mL auto-injector or prefilled syringe


01/01/2020 Trelstar® (triptorelin pamoate)

3.75mg, 11.25mg, 22.5mg intramuscular

suspension

Prior Authorization Criteria Addition MB, PA, SP

01/01/2020 triameterene (generic for Dyrenium)

50mg and 100mg capsule

Tier Change (changed from Tier 3 to

Tier 4)

T4 spirinolactone tablet (25mg, 50mg, 100mg) -T2

01/01/2020 Tudorza Pressair® (aclidinium bromide)

400mcg/actuation

Tier change (moved from T4 to T2) T3, QL


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



01/01/2020 Xeljanz®(tofacitinib)

10mg immediate release or 11mg extended

release tablet


01/01/2020 Zumandimine (drospirenone/ethinyl estradiol)

3/0.03mg tablet


03/01/2020 Divigel® (estradiol) 1.25mg/1.25gm transdermal gel


03/01/2020 Katerzia™ (amlodipine) 1 mg/mL oral suspension

Formulary Addition T4, AL

03/01/2020 lamotrigine ER (generic for Lamictal XR®) 50mg/100mg/200mg/250mg/ 300mg tablets


03/01/2020 levetiracetam ER (generic for Keppra XR®) 500mg/750mg tablets


03/01/2020 Lokelma® (sodium zirconium cyclosilicate) 5g/10g packet


03/01/2020 Mavenclad® (cladribine) 10mg tablets


03/01/2020 Mayzent® (siponimod) 0.25mg/2mg tablets


03/01/2020 olopatadine

0.1% (5mL), 0.2% (2.5mL)

solution (generic for Patanol® and Pataday®)

Step Removal T2, QL (0.01%)

T4, QL (0.02%)

03/01/2020 Nitro-Time® (nitroglycerin)

2.5mg ER capsules Tier Change (moved from T1 to T2) T3

03/01/2020 Rozlytrek™ (entrectinib)

100mg/200mg capsules Formulary Addition T5, PA, SP

03/01/2020 Secuado® (asenapine)

3.8mg/24hr, 5.7mg/24hr, 7.6mg/24hr

transdermal patch

Formulary Addition T5, QL, PA, AL


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



03/01/2020 Veltassa® (patiromer)

8.4g/16.8g/25.2g packet


03/01/2020 Actemra® (tocilizumab)

80mg/4mL, 200mg/10mL, 400mg/20mL

intravenous solution; 162mg/0.9mL

auto-injector and prefilled syringes


03/01/2020 Cinvanti® (aprepitant)

130mg single-dose vial

Criteria Update MB, PA

03/01/2020 Cipro® (ciprofloxacin)

500mg/5mL (10%) oral suspension Tier Change (moved from T1 to T2) T3

03/01/2020 Crysvita® (burosumab-twza)

10/20/30 mg/mL in a single-dose vial Criteria Update MB, PA

03/01/2020 diclofenac gel 1% (generic for Voltaren

Gel®) 1% topical gel Update Quantity T3, QL (300 grams per 30 days)

03/01/2020 Dysport® (abobotulinumtoxinA)

300 or 500 unit powder for injection Criteria Update MB, PA

03/01/2020 eszopiclone (generic for Lunesta®)

1mg/2mg/3mg Criteria Removal T2, QL

03/01/2020 Extavia® (interferon Beta-1B)

0.3mg subcutaneous kit Step Removal T5, QL, SP

03/01/2020 Flumadine® (rimantadine HCl)

100mg tablet


03/01/2020 Myobloc® (rimabotulinutoxinB)

2,500/5,000/10,000 unit vial

Criteria Addition MB, PA

03/01/2020 naratriptan (generic for Amerge®)

1mg/2.5 mg tablet Step Removal

1mg: T4, QL

2.5mg: T2, QL

03/01/2020 pregabalin (generic for Lyrica®)

25mg/50mg/75mg/100mg/150mg/200m

g/225mg/ 300mg capsules

Criteria Removal T2, QL


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



03/01/2020 Phenergan® (promethazine)

50mg suppositories

Formulary Removal Not Covered promethazine 12.5mg, 25mg suppositories

03/01/2020 quetiapine fumarate ER

(generic for Seroquel XR®)

50mg/150mg/200mg/300mg/400mg


03/01/2020 Quibron-T SR® (theophylline)

300mg ER 12-hour tablets Tier Change (moved from T1 to T2) T3

03/01/2020 rizatriptan tablets and orally disintegrating

tablets (generic for Maxalt®, Maxalt ODT®)

5mg/10mg tablets

Step Removal T2, QL

03/01/2020 Ultomiris® (ravulizumab-cwvz)

300mg/30mL single-dose vial Criteria Update MB, PA, SP

03/01/2020 Verelan® (verapamil)

100mg/200mg/300mg capsules Tier Change (moved from T1 to T2) T3

03/01/2020 Videx EC® (didanosine)

400mg capsules Tier Change (moved from T1 to T2) T3, QL

03/01/2020 Xulane® (norelgestromin/ethinyl

estradiol)

35mcg/150 mcg transdermal patch

Step Removal $0, QL, AL

06/01/2020 Ameluz® (aminolevulinic acid)

10% gel

Formulary Addition MB

06/01/2020 Ayvakit™ (avapritinib)

100 mg, 200 mg and 300 mg tablets


06/01/2020 Brukinsa™ (zanubrutinib)

80 mg capsules


06/01/2020 Caplyta® (lumateperone)

42 mg capsules


06/01/2020 chlorzoxazone (generic for Lorzone®)

500 mg tablet


06/01/2020 dapsone 7.5% topical gel (generic for

Aczone®)

Formulary Addition T4, PA


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



7.5% topical gel

06/01/2020 Dexcom G6 receiver device Criteria Update T3, PA, QL

06/01/2020 Dexcom G6 Sensor Criteria Update T3, PA, QL

06/01/2020 Dexcom G6 Transmitter Criteria Update T3, PA, QL

06/01/2020 didanosine (Videx EC®)

250mg capsules Tier Change (moved from T2 to T3) T3, QL

06/01/2020 Dulera® (mometasone furoate/formoterol

fumarate dihydrate)

50/5mcg,100/5mcg, 200/5mcg per actuation

Formulary Addition T4, ST, QL

06/01/2020 Enhertu® (fam-trastuzumab deruxtecan-nxki )

100 mg vial


06/01/2020 everolimus (generic for Zortress®)

0.25mg, 0.5mg, 0.75mg oral tablet

Formulary Addition T5, PA

06/01/2020 Freestyle Libre® 14 day reader device Criteria Update T3, PA, QL

06/01/2020 Freestyle Libre® 14 day sensor Criteria Update T3, PA, QL

06/01/2020 Freestyle Libre® Reader Device Criteria Update T3, PA, QL

06/01/2020 Freestyle Libre® Sensor System Criteria Update T3, PA, QL

06/01/2020 Guardian™ 3 Sensor Formulary Addition T3, PA, QL

06/01/2020 Guardian™ 3 Transmitter Formulary Addition T3, PA, QL

06/01/2020 Humulin® U-500 (insulin, human regular)

20 mL vial, 3 mL flexpen Criteria Update T4, PA, QL


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



06/01/2020 hydrochlorothiazide

12.5 mg tablet

Formulary addition T2

06/01/2020 hydroxychloroquine 200mg tablets

Criteria Added T2, PA

06/01/2020 Ibrance® (palbociclib)

75mg, 100mg, 125mg oral tablet


06/01/2020 Jaimiess (levonorgestrel/ethinyl estradiol/

ethinyl estradiol)

(0.15-0.03mg (84)/0.01)


06/01/2020 Lo-Jaimiess (levonorgestrel/ethinyl estradiol/

ethinyl estradiol)

0.1-0.02mg (84)/0.01 mg tablets


06/01/2020 Mavenclad® (cladribine)

10 mg tablet Criteria Update T5, PA, SP, QL

06/01/2020 Nerlynx® (neratinib)

40 mg tablets Formulary Addition T5, PA, QL, SP

06/01/2020 nitrofurantoin

25 mg/5mL oral suspension Criteria Update T4, AL, QL

06/01/2020 Padcev™ (enfortumab vedotin-ejfv)

For Injection: 20 mg and 30 mg Formulary Addition MB, PA

06/01/2020 penicillamine (generic for Depen®)

250 mg tablet Formulary Addition T5, PA, QL

06/01/2020 Sarclisa® (isatuximab-irfc)

100 mg/5 mL, 500 mg/25 mL vials Formulary Addition MB, PA

06/01/2020 Sunosi™ (solriamfetol)

75mg and 150 mg tablets Formulary Addition T5, PA, QL, AL

06/01/2020 Tazverik™ (tazemetostat)

200 mg tablets Formulary Addition T5, SP, QL

06/01/2020 testosterone enanthate (generic for Delatestryl®) 200mg/ml for injection

Tier Change T3, PA


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



06/01/2020 Tiadylt ER® (diltiazem extended release beads

capsules)

120mg/24hr, 180mg/24hr, 240mg/24hr,

300mg/24hr, 420/24hr


06/01/2020 Volnea® (desogestrel; ethinyl estradiol)

(0.15-0.02/0.01mg (21/5))


06/01/2020 Xeljanz XR® (tofacitinib citrate)

22mg base equivalent


06/01/2020 Xyrem® (sodium oxybate)

500 mg/mL solution Criteria Update T5, PA, AL, QL

06/01/2020 zinc sulfate

3mg/mL IV solution Formulary Addition MB

09/01/2020 Braftovi® (encorafenib)

75 mg capsules Specialty Pharmacy Mandate Addition T5, PA, QL, SP

09/01/2020 Dayvigo™ (lemborexant)

5 mg, 10 mg tablets Formulary Addition T5, PA, QL

09/01/2020 Delstrigo™ (doravirine, lamivudine, and

tenofovir disoproxil fumarate)

100 mg/300 mg/300 mg tablets


09/01/2020 Epclusa® AG (sofosbuvir/velpatasvir)

400/100mg oral tablet


09/01/2020 Eucrisa® (crisaborole)

50 gram, 100 gram tube

Criteria Update T5, PA, QL

09/01/2020 Farxiga® (Dapagliflozin propandediol)

5mg, 10mg tablet

Tier Change T3, ST, QL

09/01/2020 Flowtuss® (hydrocodone/guaifenesin)

2.5 mg /200 mg/5 ml solution


09/01/2020 isoniazid

100 mg tablets

Tier Change T3

09/01/2020 Jelmyto® (mitomycin)

40mg vials

Formulary Addition MB, PA, QL


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



09/01/2020 Mavyret® (glecaprevir/pibrentasvir)

100 mg/40 mg tablets


09/01/2020 midazolam

2 mg/2 mL, 5 mg/5 mL, 5 mg/ml, 10 mg/2 mL

solution for injection

Formulary Addition T2, ST

09/01/2020 Nayzilam® (midazolam)

5mg/0.1mL bottle Formulary Addition T5, PA, QL

09/01/2020 nicardipine HCl

20mg/200ml, 40mg/200mL intravenous

solution

Formulary Addition MB

09/01/2020 Ofev® (nintedanib)

100 mg, 150 mg tablets

Update prior authorization criteria.


09/01/2020 Oriahnn® (elagolix, estradiol, norethindrone)

300mg/1mg/0.5mg tablets


09/01/2020 Pemazyre™ (pemigatinib)

4.5 mg, 9 mg, and 13.5 mg tablets


09/01/2020 PifeltroTM (doravirine)

100mg oral tablet


09/01/2020 ribavirin

200 mg tablet, 200 mg capsule


09/01/2020 romidepsin

27.5mg/5.5mL intravenous solution


09/01/2020 Strattera® (atomoxetine)

10mg, 18mg, 25mg, 40mg, 60mg, 80mg,

100mg capsule

Criteria Update T4, PA, QL, AL

09/01/2020 Trodelvy™ (sacituzumab govitecan-hziy)

180 mg single-dose vials Formulary Addition MB, PA

09/01/2020 Tukysa™ (tucatinib)

50 mg and 150 mg tablets Formulary Addition T5, PA, QL, SP


MPC011711 of 14 Updated 09/01/2020

Effective Date

of Change



09/01/2020 Udenyca® (pegfilgrastim-cbqv)

6 mg/0.6 mL pre-filled syringes

Formulary Addition MB, PA, SP

09/01/2020 Voltaren® (diclofenac sodium)

1% gel

Formulary Removal NF Naproxen (T2)

09/01/2020 Wakix® (pitolisant HCl)

4.45mg, 17.8mg tablet


09/01/2020 Xigduo® (dapagliflozin/metformin)

10/1000mg, 10/500mg, 2.5/1000mg, 5/1000mg,

5/500mg oral tablet

Tier Change T3, ST, QL


500mg/ml oral solution Formulary Addition T5, PA, QL, AL


500mg/ml oral solution Criteria Update T5, PA, QL, AL

09/01/2020 Ziextenzo® (pegfilgrastim-cbqv)

6 mg/0.6 mL pre-filled syringes Formulary Addition MB, PA, SP

09/01/2020 Zyrtec® (cetirizine)

5mg, 10mg oral tablet Formulary Addition T2, QL

MB= Medical Benefit, PA = Prior Authorization required, QL = Quantity Limit, SP = Specialty Pharmacy required, ST = Step Therapy

Learn more about Presbyterian’s Nondiscrimination Notice and Interpreter Services.

http://docs.phs.org/idc/groups/public/documents/communication/pel_00229074.pdf

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